Provider Demographics
NPI:1992208912
Name:VANCLEAVE, HEATHER RENEE
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RENEE
Last Name:VANCLEAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:EIDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9979 FM 773
Mailing Address - Street 2:
Mailing Address - City:MURCHISON
Mailing Address - State:TX
Mailing Address - Zip Code:75778
Mailing Address - Country:US
Mailing Address - Phone:903-288-1546
Mailing Address - Fax:
Practice Address - Street 1:1228 LOUANN LANE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-539-2267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210653224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant